By Dr Jeb McAviney BSc., MChiro., MPainMed., FCBP

Adolescent Scoliosis in the Adult (ASA) & Degenerative De-Novo scoliosis (DDS)

Adult Scoliosis ASA is pre-existing AIS but in adulthood DDS is a new development of scoliosis in adulthood. The primary concern in most adult cases is Pain Progression and Aesthetics are also considerations

ASA 1 Usually smaller flexible curves in younger adults years old Posture and Cosmetic issues are the main problem. Pain can be an issue particularly in unbalanced curves Potential reducibility in both abnormal posture and Cobb.

ASA 2 Usually larger more rigid curves in middle aged adults Pain and posture equally issues. Pain can be an issue even in balanced curves. Often start to see early degenerative changes Intervention in ASA 2 could potentially to stop progression to ASA 3

ASA 3 Usually large, rigid curves in older adults 40+ Pain is the primary issue. Moderate to severe degenerative changes present. Most commonly lumbar curves. No previous history of scoliosis could indicate Degenerative De Novo Scoliosis DDS.

Degenerative De-Novo Scoliosis (DDS) New curve in adult developed as a result of degenerative instability. Usually lumbar curve, unbalanced. Large, rigid curves in older adults 50+ Pain is the primary issue. Moderate to severe degenerative changes present.

Prevalence of Adult Scoliosis in Back Pain Perennou et al; 671 LBP patients: 7.5% had evidence of scoliosis. Prevalence of scoliosis increased with age; 2% before 45 years (most likely ASA) 15% after 60 years (probably DDS)

Prevalence of Adult Scoliosis in Back Pain Robin et al; 554 LBP patients Aged 50 to 84 30% scoliosis >10° At 5 year follow up 40% scoliosis >10° Additional 10% “a significant number of older people have an adult scoliosis” and its prevalence and progression is directly related to advancing age”

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002, ASA mean, 40° DDS mean, 25° Radiographic parameters correlating with pain were identical for these groups This appears to substantiate the belief that a common end pathway (degenerative instability and unfavorable lumbar vertebral alignment) among both groups of patients is related to symptoms rather than the degree of curvature or the cause of the original scoliosis.

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002, Schwab’s research identifies these radiographic parameters as important: Level of regional balance. Instability Pathologic mechanical loads of the spinal elements

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002, He identifies these correlations with pain: Lateral vertebral olisthy, (side slip) L3 and L4 endplate obliquity angles, Decrease in lumbar lordosis, Increased thoraco-lumbar kyphosis

“Adult Scoliosis - A Quantitative Radiographic and Clinical Analysis”, Schwab et al. Spine 2002, The Cobb angle of the scoliotic deformity had no statistically significant correlation to the VAS. Early intervention in a middle-aged adult with scoliosis may be preferable to treating advanced deformity in that same person once he or she has become elderly.

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine patients The purpose of the study was to correlate radiographic measures of deformity with patient-based quality of life and health status assessments in adult scoliosis.

“Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003 The most significant findings were: Positive (anterior) Sagittal Balance Greater pain Diminished physical function Poorer self image Poorer social function

Coronal shift > 4 cm Poorer function Greater pain Compared to patients with a coronal shift < 4 cm. “Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003

Key Points Positive (anterior) sagittal balance predicts clinical symptoms in adult spinal deformity. Thoracolumbar and lumbar curves have worse outcomes than thoracic curves. Significant coronal imbalance was associated with pain and dysfunction. “Correlation of Radiographic Parameters and Clinical Symptoms in Adult Scoliosis” Glassman, et al. Spine 2003

Progression of Adult Curves Progression in ASA 1&2 is generally not a major concern unless the curve is already very large >60 deg Danielson and Nachemson in Spine 2003 found that 36% of adolescents with scoliosis had progressed by more than 10° after 22 years. ASA 3 and DDS can become moderate to severely progressive due to degenerative instability and or hormonal influence. The most progressive DDS cases often have osteoporosis as a co- morbidity

Progression of Adult Curves Spinal Degeneration Soft tissue integrity lost Functional unit instability increased Scoliosis Progression Boney adaptation (Wolffs Law)

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 Two main types were identified: 1) Type A Adolescent scoliosis Progresses after skeletal maturity

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 Two main types were identified: 2) Type B Progresses late in adulthood: Pre-existing stable adult scoliosis with late progression De novo late-onset scoliosis.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 Progression was measured at a liner rate specific to each curve. “We did not find any correlation between the initial Cobb angle and slope of progression in the overall population.”

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 Role menopause plays In 8 women with type A scoliosis with a long progression comprising menopause, no change of slope was observed at menopause. Patients with type B scoliosis were all women and exclusively presented a lumbar or thoracolumbar single curve. In type B, 11 out of 20 of these patients progressed at the time of menopause.

Natural History of Progressive Adult Scoliosis Marty-Poumarat et.al. Spine 2007 Summary The progression of adult scoliosis is linear. It can be used to establish an individual prognosis. Two main types exist: Adolescent scoliosis, which continues to progress (type A) ASA 1&2 Late onset scoliosis, either pre-existing stable adolescent scoliosis or de novo (type B). ASA3 & DDS Menopause constitutes a period of deterioration for type B.

Progression of Adult Curves Type B Soft tissue integrity lost Functional unit instability increased Rotational Subluxation Scoliosis Boney adaptation (Wolff’s Law) Boney Degeneration

Progression of Adult Curves Type BM Soft tissue integrity lost Functional unit instability increased Rotational Subluxation Scoliosis Boney adaptation (Wolff’s Law) Boney Degeneration Menopause

DDS Development 50 yr old woman minor LBP 5 years latter developed DDS

Adult Scoliosis Treatment Increased Life Expectancy vs. Long term Quality of Life Degenerative pathologic conditions in aging persons are increasingly of concern in regards to long term quality of life and independence The focus of medical treatment in Adult cases is usually on regional degenerative pathologic conditions such as stenosis, spondylolisthesis, disc degeneration etc. rather than the deformity itself! “Although the common degenerative conditions of the spine are frequently treated as focal pathologic states, it appears intuitive that deformity of the spinal column, by altering the mechanical loading conditions, can accelerate the degenerative cascade.” Schwab et al, Spine 2002

Adult Scoliosis Treatment Rigid vs. Dynamic Orthosis for Treatment Rigid Dynamic Muscle Atrophy in unstable system Limitation of movement Self image issues Comfort issues Useful in Neuro-degenerative cases Muscle rehabilitation and stabilization Allows movement Not visible under clothing Relatively comfortable Suitable for long term use Not suitable for Neuro- degenerative cases Goal is improvements in Sagittal and Coronal balance not a forced reduction in Cobb angle

Corrective Movement & Spinal Loading

CLASSIFICATION CORRECTIVE MOVEMENT BRACE IN PLACE LEFT LUMBAR SpineCor Adult Treatment

SpineCor and Sagittal Balance Corrective movement for Anterior Sagittal Balance First have the patient stabilise their lordosis by the contraction of abdominal and gluteus muscles. Second translate the base of the thorax slightly forwards and upwards.

SpineCor Adult Brace

Examples of Adult treatment Patient A  26 year old female,  Painful adolescent idiopathic scoliosis as an adult (ASA1).  Pain 7/10.  8 to 12 hours for 3 months  Gradual relief of pain to 2/10.  32 deg right thoracic scoliosis.  Improvement of 8 degrees to 24 deg.  Relief of 1-2/10 and spinal correction have been maintained for over 2 years. Courtesy of Dr Tom Pappas

Examples of Adult treatment Patient B  47 year old female  Degenerative De-Novo Adult Scoliosis. (DDS)  Pain 7/10.  Immediate relief of pain to 3/10.  A 40 deg degenerative lumbar scoliosis.  Improvement of 7 degrees to 33 deg.  Pain relief of 0-3/10 maintained for over 2 years  Note the improved left lateral shift showing “spinal off loading”. Courtesy of Dr Tom Pappas

Thank you